In response to the devastating earthquake in Haiti, physicians, nurses, and staff at NYU Langone Medical Center came together to form the Haitian Effort and Relief Team (NYULMC HEART). On Friday, January 22, 2010, the first group of HEART volunteers arrived in Haiti to provide surgical services at General Hospital in Port-au-Prince. During their one-week stay, they are sharing their experiences and reflections on this page.

The word to describe today is extremes. Extremes of life and death, of selflessness and ego-mania, of calm and chaos, of hope and despair. How individuals survive life's relentless pendulum is a mystery to me - I barely survived one day.

What people don't say when they are reporting on Haiti is that Haitians are still living. There is so much focus on death and desperation (people who still have homes and intact families and food and health can afford to dwell on death and glamourize desperation) that we all forget for millions of Haitians, on the morning of January 13th they had no choice but to wake up and continue living.

On our way to L’Hopitale Generale (HUEH) this morning I am struck by the liveliness – the cafes serving food, the marchandes arranging their wares in the marketplace, baskets balanced perfectly on their heads, the camionettes, brightly painted, horns blaring, whizzing by on the roads packed with passengers all on their way to the rest of their lives. All this set against a backdrop of rubbles, stone tombs that now house the remains of loved ones. I am so proud to be Haitian in this moment – to bear witness to their strength and resilience is life-altering.

We arrive at HUEH and I am stunned. Tents occupy all areas of outdoor space, and under the tents patients. Mattresses on the floor, broken stretchers, old cots all packed together tightly to make space for people – but this is not what surprises me. It is something about the appearance of the tents themselves that is shocking. Each tent is adorned with someone’s flag, symbol, color, alphabet soup, tribal tattoo – anything to distinguish one organization’s colony from another. Anything to symbolize that despite the fact that they are on Haitian soil, in a Haitian Hospital Haitian rules don’t apply in this tent. This tent is an extension of our country, our culture, our norms, so please present your passport prior to entry. Yet at the same time, I am also overwhelmed by the international representation; taken aback by the notion that the Norwegian Red Cross cares enough about this western third of a tiny island in the Caribbean that they would travel across of the globe to come care for our wounded. I am angry and impressed, resentful and grateful. I am conflicted.

I find my way to the pediatric unit and walk around. 5 large tents, 2 small. The large tents are divided into 1 pre-surgical, 2 operating rooms, 1 post-surgical, 1 medical. The small tents are used for medical triage. Interspersed there are additional large tents where I hear women wailing – Maternity. The children lie on mattresses and mats strewn on the ground. Space is tight and it is difficult to tell which parents belong to which children, as the adults are forced sit, squat, and lie in the 2 inch space that may or may not separate the beds. I am in the post-op tent and most of the children wear browning casts and bandages. I find a child in the corner lying on his mattress, a piece of cardboard wrapped around his calf with a bandage, his leg leaning up against a chair, the end of the bandage tied to a water bottle slung over the back of the chair. I ask the Mother what his diagnosis is and she tells me he has a fracture. Traction. There are no sheets, and no hospital gowns. Patients wear the clothing they have, often tattered and bloody. The heat has begun to rise (the tent’s construction allows for no ventilation) and flies are everywhere. I hear a girl whimper “mouches” as she swats flies away through tears. There are no functioning bathrooms so children, even potty-trained ones are forced to use diapers. Unfortunately there are not enough diapers to go around, and the older children don’t have diapers that fit. I later find out that the Hospital can only afford to provide one meal a day to these children, and that parents who may have otherwise had means to buy some food outside the hospital for their children do not dare leave as they risk not being allowed back onto hospital grounds.

I inquire as to who is in charge, and get three answers. I choose to search out the one Haitian name in the group. I fall, instead, upon an American - a pediatrician in training, cutting her teeth on disaster relief. I introduce myself (first names only here) and offer assistance. She quickly tells me the tents are run by the Swiss, and that this is the Swiss Hospital. “Really?” I think, “I thought it was HUEH.” (inside voice). She then proclaims her love for me since I speak the language of the country she is currently in (not Switzerland – Haiti) and begins to turn away. I hear a child moaning and turn to the direction of the sound, “What’s wrong” I ask the Mother. She shrugs and points to his left arm and leg. “I think they are broken – they hurt him so much.” The child has what appears to be a fracture of the left humerus and a compartment syndrome, old now, of his L femur. I turn to my colleague and ask her if the child has been seen by a surgeon. She replies, “the Swiss will get to him.” I am confused. “We have a pediatric orthopedic surgeon from NYU who has arrived with me today and is anxious to see patients. I can have him come down and see this child now.” I tell her. “Well, we shouldn’t steal the Swiss patients.” She responds. Swiss patients? These are all Haitian patients! Stealing patients? The number of dead and injured is said to be somewhere around 500,000 – I didn’t think stealing patients would be an issue. I am annoyed. I need to find the Swiss.

I go to the pre-op tent and I introduce myself to two elderly, perspiring, white gentlemen and am told one is in charge of the surgical patients, and the other is in charge of the entire “Swiss Pediatric Hospital”. The tent is full of patients waiting to be seen. I give them my credentials, explain to them that most of the work I do is peri-operative care and offer any help they might need. The physician in charge of the entire peds unit begins to pull me aside. At first I assume I am in the way of a patient transport, but I realize he is leading me outside the tent. I am confused. He continues to pull me gently by the arm until we are beneath the shade of a pye zanman. He proclaims in French, “Oh yes, much better…now I can talk. It is absolutely stifling in those tents…”

I think I am in an alternate universe. I decide to just start with the basics: see patients. I speak with the nurses and there is a new admission: a one month old with vomiting and mild dehydration. I speak with Mom and she tells me that the infant takes breast milk without difficulty but when she gives him Gerber he vomits. I explain to her that he is too young for baby food, and that she should stick with her breast milk. She confides in me that she has not been eating well, and knows her supply is dwindling. She fights back tears. I excuse myself, as I fight back my own. The pain of being unable to provide for your child is difficult to describe. Words like “searing” and “suffocating” come to mind. I think about my second son, a beautiful chubby 5 month old that knows nothing but breast milk. I reflect on the interruption of his nursing routine caused by this trip, my anxiety about how much milk I left stored for him, whether he would run out and have to be given formula, whether he would take the formula, whether I could keep my milk supply up while in Haiti. I compare my anxiety to her fear, my circumstances to her fate, my choice to be here to her doom. I try to rationalize the disparity between my son’s life and hers. My mind is racing; emotions and professional judgment, duking it out, and I need to go back to the bedside. I ask her to demonstrate her feeding technique. He latches on well, and she is producing some milk. We have no formula to give out to parents. I tell her if she can afford to by Gerber, she should save that money to buy food for herself and nurse him vigorously. She looks hopeless. I tell her I am nursing, and can give her my breastmilk if she wants. She shakes her head. I apologize for having nothing else to offer her. Her son voids. I tell her we will keep him for some hours of observation, but that I don’t think he will stay the night. She smiles, weakly…obviously disappointed…

…A tall well-dressed man approaches me and says excitedly in French, “Are you aware that the First Lady is here to visit the ward?” I shake my head, disinterested. In what seems like mere seconds the tent is descended upon by cameras, and microphones. A petite silver-haired woman in a neat business suit adorned with a scarf, her haired pulled neatly in a chignon, walks in to the ward and shakes my hand as she feigns interest in the patient beside me. She poses for several photographs. The Mothers in the room stare silently. She touches a child’s hand snap, flash, puts her arm around a mother snap, flash. My American colleague arrives and shakes the First Lady’s hand, obviously excited snap, flash. I leave the tent, annoyed…

…As I walk away, I pass another group of cameras orbiting around the universe of Sanjay Gupta, MD…more annoyed…

I see a small group of people running towards me. One of them is carrying a baby, he shouts,” Where is Peds?” I run up to them and realize one is holding a newborn, one man is giving chest compressions and one is bagging. I ask them to follow me and begin running back to the tent. “What’s the story?” I ask. “We have no idea. Someone just handed us this baby.” We run pass Sanjay, and back to the tent. We lay her down. She has no pulse. “Does anyone have a story?!” I shout. “She’s an ex-32 wker. 2 days old. She’s been seizing 20 minutes or more.” “Can I have Ativan?” I scream to no one in particular. I ask them to stop bagging – no spontaneous respirations. “Can I have 3.0 ET tube?” again to no one. I hear back, “We don’t have any of that doc!” I look around as the EMT continues to bag her with a mask that is entirely too big for her face. No chest rise. My colleague is back. “What’s going on?!” she yells. Someone gives her the story. She feels for pulses. “Guys, we can’t do anything with this kid.” she shrugs. The EMT is relentless and continues with chest compressions. I feel for a pulse again. “She has a pulse!” I scream, but realize I have nothing with which to intubate her. There is no pediatric crash cart in the peds tent, and the EMT’s only have adult resuscitation equipment. EMT one is bagging, EMT two is giving chest compressions. I run out of the tent and to the OR….

Daiana is at the head of a table with David and Ken hovering over a patient. They are operating, she is monitoring. The OR is cool and calm (speaking comparatively, of course). “Daiana! I need a 3.0, a blade, Ativan, epi and atropine!” I can barely speak. She runs over to me and starts rummaging through boxes. She hands me the tube and the blade and a vial of valium after what feels to be an eternity. I run out, followed (unbeknownst to me) by two nurses…

We run past Sanjay again, and push one of his entourage out of the way. We arrive at the tent. As I approach the bed, one of the nurses announces, “ I am a pediatric nurse anesthetist. I can get that airway.” I quickly hand over the tube and blade to him. He secures the airway. I administer the valium. “She needs to go to the Comfort.” someone shouts. We lift her and bring her to an army truck that will take her. The nurses accompany her to the ship…the back of the army I sigh, exhausted and sweating…it’s only 2:30 I feel like I have been here forever…

We are back. Ten days ago we all embarked on an incredible journey to do some incredible things. Although we succeeded in many ways, this is no time for pats on the back or congratulatory high-fives. We all return home with a terrible nagging sense that there is so much more to do. Ken began designing proposals for future efforts and sending emails out as early as Saturday morning, while I received a panicked voicemail from Daiana Saturday night, "Did we leave too soon?". David and I spent time between his cases today discussing what our next steps in Haiti should look like.

It is now our responsibility to take the observations made during those eight days and distill them into a plan for the future. What role do we want to play during this tragically historic moment in Haitian history? What will our relationship with Haiti look like next week? a month from today? a year from today?

Unlike our fearless leader, Fritz, I did not have access to email or the internet while in Haiti. As a result all my thoughts and observations on the trip were recorded the good old-fashioned way: in a journal. Now that we must look back, I find myself leafing through that journal, compelled to share some of my experiences, as a woman, as a Haitian-American and as a physician.

1/22/10

We are here. Its been 11 years since I was last in Haiti. I traveled in 1999 for Carnavale - I have such vivid memories of carefree celebration - so different from now. Prior to 2000 my travel to Haiti was fairly regular - at least once yearly - occasionally for volunteer work in Hospitals and clinics, mostly for fun. I was born in the US to fanatical parents that felt it their duty to instill in their children "Haitian Pride". I have always had family and friends to visit which served as a great excuse to take the 4 hour plane ride out of JFK, but frankly my trips to Haiti were much more than just social jaunts. I felt overwhelmingly grounded when I was in Haiti - plugged into my family and history in a way I never could be in the States. There is something about being surrounded by your parents' spoken language that is transformative. I loved going to Haiti...

On 1/12/10 I was on my way out of the hospital when my husband told me about the earthquake. He had not heard yet from my parents or his Father. We didn't understand the gravity of what had occurred until hours later. We spent the next several days trying to contact family, hearing news of those who were fortunate and those who were not, watching gruesome footage still in disbelief. My parents were Ok, and so were my uncles...eventually we received word from my Father-in-Law...then we began planning the trip....

So now we are here. Its dark out, and I haven't seen the city - all the better, I think. My colleagues comment about the smells, but all I smell is Port-au-Prince. "When the level of destruction hits me," I think to myself," I'm going to lose it...but not now. Now I'm OK." I speak to our driver and ask questions about the general state of things. "We've been sent back to zero and have to start once again from there," he says in Kreyol. "I estimate that after all of the injuries and the amputations 40% of Haitians will be disabled. What in the world are they going to do now? Haiti is no place for someone disabled." I nod in agreement and sit back. After 206 years of independence "zero" is a terrible place to start...

The early hours of the afternoon marked a steady stream of apprehensive patients arriving in the waiting area of the operating room (#22 on map) where David Feldman, Ken Mroczek, Mary Ann Hopkins, and Diana Voiculescu continued to immobilize bones, deep clean wounds, and explore abdomens.

A man on a stretcher examined his x-ray with great fascination while waiting his turn. To anyone who approached he would offer a well rehearsed argument against any surgery on his leg for fear that it would be amputated:
"Moin pa we anyen la. Moin bon" (I don't see anything here. I'm good)
In fact, the x-ray showed a clear tibial fracture.

In the pediatric tent (lower right corner on map), Patricia Poitevien had just identified a child who was slowly drifting towards respiratory distress. Without the benefit of mechanical ventillators an intubated child would need someone to stay by the bed and manually squeeze precious air into the lungs with the aid of an ambu bag.
Where were the ambu bags anyway?
The best option for the critically ill was to arrange for a transfer to the US medical ship, The Comfort. Some nearby children cried from hunger while still others laid quietly on their backs staring up at the bland ceiling of the tent.
No dancing bears, smiling clowns, or goofy duck characters would entertain them.

Nestled in between the pediatric areas, were two other tents that had been designated as Maternity Wards (lower right corner on map). It was there that Prisca Bernard-Joseph held hands, administered pain medication, and gave encouragement to pregnant women who at times seemed preoccupied with the uncertainty into which they would deliver their children.
Why hurry up and push? This was not a place for children to set their sights.

Back on the dimly lit and poorly ventilated critical care unit (#6 on the map) tensions were mounting between the patients and the legions of flies that seemed to have summoned reinforcements.

Groups of them swarmed around day-old soaked bandages and tried to land on exposed skin.

At times the number of insects that successfully remained in close proximity of a patient became an early warning system to the deteriorating condition of that individual.
With only two nurses for all the patients on the unit it was impossible to attend to everyone's needs in a timely fashion. The situation was made worse by the fact that the two english speaking nurses had only one interpreter to share. Yet these patients and families who had already endured so much hardship, were steadfast in the dignified and patient manner in which they dealt with the situation.
Many patients suffered quietly until the very last moment when the unbearable pain would drive them to the edge of consciousness. At that point a very faint plea might emanate as I passed by:
"Dokte, fe ou bagay pou moin" (Doctor, do something for me).
One of the quietest patients was a 17 year old boy who days before had presented with massively swollen legs from crush injuries. He now wore precisely made foot-long surgical incisions down both sides of each leg. While these unsightly fasciotomies saved his lower limbs in the short term by releasing built up pressure, they now threatened to take his legs by being portals to possible infections...as his daily fevers (despite antibiotics) would suggest. He never watched when his bandages were being changed, choosing instead to bury his face in his right arm. He remained in that position well after cleaning solution had been applied to the raw wounds, poorly healing tissue had been scrubed or cut out, and new bandages had been applied. Only the rapid rise and fall of his chest hinted that the pain medication he had received prior to the wound care might not have been sufficient.
He did not ask but graciously accepted the morphine that I brought him.
"Merci" (Thank you)
I tried to get him to talk.
-So what do you think of Wyclef?
"He's good."
-Yeah? Sounds like you have another favorite.
"I don't have a problem with him. He's okay."
-What about you? Are you a musician?
"Not really. I just play sports."
All of a sudden I regretted the direction of the conversation.
He shifted to pull himself up in the bed and grimaced as he did so.
"Before this...I wanted to be a professional soccer player...that's what I WANTED"
He emphasized on the past tense.
My stomach sank.
Two transporters arrived to take him to the dialysis unit run by Medecins Sans Frontieres.
He was on his second session for rhabdomyolysis.
I touched his arm and offered
-Kenbe fem (hold firm)
He nodded and simply buried his face in his right arm again as he was carried away.

Ken Mroczek and I joined the NYU/HJD mission to Haiti as the orthopedic contingent. We joined with Partners in Health (a non-profit nongovernmental organization that has a long and important history in Haiti). There were seven of us in all with different specialties and expertise. We all had different expectations and concerns and with three in the group being Hatian-American we had varied knowledge of the Hatian people, language and culture.

On the plane ride over we discussed how we would do whatever it took to help in some small way. As a surgeon, I had been very impatient in the week leading up to our departure because I knew that every day that passed my input and ability to change a patient’s outcome would diminish. We arrived in the early evening to the smell of a smoldering city and an airport and country that was in near total chaos.

The week mission is over now. I am home in the comfort of hot running water, warm meals and a comfortable bed. I would like to share what I learned as a person, physician, division chief, and administrator. There are many facets to this learning experience and several had little to do with the crisis itself.

To describe the setting, we were placed in the largest hospital in Haiti which is the general hospital in Port-au-Prince. Even before the earthquake this was a hospital with very few resources and a barely functioning operating room. Port au Prince at this times looks like the pictures I have seen of Dresden during World War II. There are very few buildings still standing, with rubble and exposed wires everywhere. The dust, heat and smell of decaying bodies permeate the city. Tent cities are scattered throughout the parks with the bustle and traffice of a chaotic city continuing. The Hatian people are a proud people who are quite fastidious concerning their personal appearance. Even in this tragedy, nearly to a person, they were clean and well dressed with the white of their shirts whiter than white. Considering it is a city now with no running water or electricity, this is quite a fete. While I am sure there is crime, like any big city, we never felt threatened in any way and on our last day four of us walked through the city without any need for an armed guard.

We were sleeping in a courtyard of what appeared to be a school at the end of a runway at the airport. We had running water by day three but I never got used to the sound of C17 cargo plane one hundred feet above my head at 2 AM. Our camp was between 20 minutes to an hour away form the hospital depending on how much coffee the driver had that morning or afternoon.

I will start with what I saw and learned as a surgeon in order to help other orthopedic surgeons who wish to do similar work. First one must place his or her own ego aside in doing a mission like this. It is not about doing the “greatest” case or being recognized for saving a limb or a life. There are no surgical heroes in these situations and this is neither a movie nor a CNN special. We are not discovering the cure for cancer; we are simply contributing a service where we are needed. If at home you have residents to make rounds and change dressings that does not exist here. No matter how senior, we all changed dressings (Mary Ann reminded us of this until it became second nature), looked at surgical wounds, placed IVs and transported patients.

Second, one must know their skill set. Ken and I witnessed surgeons and non-surgeons performing procedures that was not at all what they were trained to do. This is not okay. If there are others to help you, then use that help and assist them. Fritz and Pat did what they did best, cared for sick adults and children respectively. We joined our surgical team with another Partners in Health group from Boston Children’s, Bringham and Women’s and MGH that included trauma/vascular surgeons and Plastics/Ortho surgeons . This relationship, as I will discuss later, allowed us to accomplish more than we ever expected. There is no credentialing committee in crises and one must know their own skills and defer to others to achieve the best result. Because of my experience with limb deformity, I placed a large number of external fixators and Ken assisted on nearly every one. For a few cases I acted as the scrub nurse and/or circulating nurse when we were short nurses. We helped each other often, in decision-making and in the surgery itself. First and foremost Ken and I always maintained the question that is what we are doing truly helping this patient in this situation? Therefore if you are reading this long winded account and you have experience with and comfotable treating orthopedic trauma, then you can certainly be of immediate help in these situations. Residents should be accompanied by attendings and not attempt to do this alone. If you do not feel comfortable with trauma, there is still help that you can render.

We had few resources and a suboptimal operating room with suboptimal sterility (especially when we first arrived). We needed to keep things simple and safe. Although certainly capable of doing so, we did not do any open reductions of fractures or intramedullary rods and made sure those cases such as a femoral shaft fracture in an adult went to an appropriate outlying facility such as the USS Comfort, a US Navy ship that had fully functioning ORs. We were also sensitive to the people of Haiti and although a number of limbs we treated may eventually come to amputation, the team salvaged all limbs and performed no amputations. The trauma victims had become very concerned that all the foreign doctors were going to do was cut off their limbs and before every surgery we re-assured the patients and their loved-ones that this was not the case. I discussed the surgery with the patient and a translator each time. While there is no informed consent forms, these are people who need to be treated with respect and caring, even in this dire situation.

The next lesson I learned is how to be part of a team and what skills are needed when entering this situation. When we arrived there was no fuctioning operating room and hundreds to thousands of people requiring surgery. No functioning x-ray for a few days. No xray in the OR at all. Patients were for the most part in multi-personed tents or outside under trees or make-shift tents. Most buildings were not habitable. There were multiple groups from all over the world setting up their own little mini-camps within the hospital and performing procedures with little resources. Within one day, with the help of nurses, techs, surgeons and anesthesiologists we had a primitive but functioning OR- suite of 4 ORs. By the second day we had joined forces with the Mount Sinai group who had come with many para-professionals including a supply chain expert (Mike) and our OR had a sterility process (even without an autoclave). With only few exceptions we worked together to make this work. We scoured the patient tents and a place we called the forest, where patients were scattered under trees in the middle of the facility. There was one physician trying to help 50 patients. We found patients with untreated open fractures, untreated pelvic and femur fractures and open and/or infected stumps. We prioritized the need and actually created with a nurse (Stella) and an anesthesilogist an OR schedule. We often made rounds with an anesthesiologist in order to make dressing changes more humane. There was a time when we had 20 patients in a tent all on Ketmaine. It was like a 1960s LSD party. We had one tent which was run by critical care and ICU nurses and we made that our post op critical care unit. These Dartmouth nurses were talented and incredibly dedicated to these patients. We could not have done it without them. As the days went by we actually created a map of the facility and with the help of BB, an emergency room doc from California, we created a pre-op unit which patients either were treated by us the French, the Swiss, the Norwegians or were transferred to other facilities. With the help of International Medical Corps (IMC) led by Paul, Bob and Anil, we were able to identify, which patients would go where and with Colonel Malsby of the US army, we became as efficient as possible in getting the patients the appropriate care they needed as quickly as possible.

How do you deal with so many small groups who were running their own show? This is a difficult question and is unique to crises. Unfortunately, several groups were more interested in the media and the cameras then in the optimal care of the patient. The media is looking for the miracle story and/or the crisis problems that care takers are not solving. For the most part these do not exist and it is never as good or as bad as some of the media portrayed. We solved this problem by constantly engaging the international groups. We used our pre-operative area to feed the French contingency surgical patients. We shared resources of equipment etc with whoever needed. I would start my day at the Swiss Pediatric tents talking to Axel, their surgeon, and seeing how I could help. Gradually barriers were broken and all was collegial if not actually friendly. Amazing that there can be turf wars when there is so little at stake. Left to nature, we would have had the Lord of the Flies. The goal was the quality of patient-care, not us. There most definitley needs to be a more coordinated multinational response team.

Let me say a few words about the us, i.e the surgeons. Ken Mroczek, chief of foot and ankle surgery at NYU/HJD, Johnathan Gates, Medical Director of trauma surgery at Bringham and Women’s Hospital, Mary Ann Hopkins, General Surgeon, NYU medical Center, John Meara, Chief of Plastic Surgery at Boston Children’s hospital, Gary Rogers, Plastic Surgeon, Orthopedic Surgeon, Hand Surgeon, JD, MBA, MPH at Boston Children’s Hospital, Joaquim Havens. Ex-Navy seal and Chief Resident of Surgery at Bringham and Women’s Hospital, Bill Perenteau, Chief Resident of Surgery at Bringham and Women’s Hospital and myself, David Feldman, Chief of Pediatric Orthopedic Surgery at New York University and Hospital for Joint Diseases. Those are all pretty impressive credentials. There was not a moment of discord between any of us in the group. Everyone did jobs from the most menial tasks to the most complex surgery without a single word of complaint. We were colleagues and we became friends. We utilized each other’s surgical skills to make the patient outcome the best it could be. One case in particular that stands out for me is a five year old girl with an infected complete degloving injury of the upper extremity with a multiply fractured and dislocated elbow. The child had been treated in another part of Haiti and was sent in with a seemingly unsolvable problem. Gary Rogers and I worked together as if we had been working together for years and jointly we were able to fix the elbow and then transport the child to the Comfort for completion of her care.

We worked hand in hand with the nurses and anesthesiologists (who were the best and most dedicated I have ever worked with) to make an operating room that was real and functioning. On our second to last day we performed 26 operations closing wounds, skin grafting and completing what we had started and on our last day we were able to transition this OR to the Hatian doctors. This is the part I am most proud of.

I have learned that the first response team MUST include trauma, plastic and orthopedic surgeons with the emergency doctors. These surgeons must be willing to be the first line in order for example to splint extremities correctly and prevent unnecessary amputations and amputations performed incorrectly. As you exit the first days of a crisis you need an internist and pediatrician to take care of sick patients, you need ER doctors to triage and treat, you need talented anesthesiologists, trauma surgeons, plastic surgeons and orthopedic surgeons. Within a week, the role of the trauma and general surgeon diminishes and you need more orthopedic and plastic surgeons. As a team who wishes to be self-sufficient, you need OR techs and experts in setting up an operating room. You need talented indefatigable OR and ICU nurses. You also need to incorporate the local people to help you in all ways from physicians to transports.

I will end this review with a word about the American Armed Forces. Unfortunately, previously I had little to no experience interacting with our armed forces. In Haiti the army maintained order and we worked closely with them. Each soldier I came in contact with was expertly trained, intelligent, disciplined, kind, helpful and dedicated. The Medics operated with us and at times they too performed the most menial tasks always with smiles on their faces. One unfortunate story was of a local doctor who delivered a full term still born child in the Swiss OR. The doctor, for unknown reasons, discarded the dead newborn child on the floor. The US medic (Patrick) asked the doctor to pick up the child. The doctor stated, “it was not his job”. The soldier instead of creating an incident, picked up the child and wrapped the body and treated it with the respect it deserved. One story and there are many others. Without the tireless work of the US army, Haiti could not have pulled through the first weeks of this crisis. We often forget, due to media reports, how incredible these true patriots are and my attitude and love of these men has been changed forever and I will support and help them in every way possible.

The cameras will soon leave Haiti except for an occasional follow up human interest or “how are they doing now?’ story. I will return to Haiti in the next six weeks and partner with an effective NGO to help follow the numerous patients treated with external fixators etc. If you wish to help don’t do it alone- lone rangers don’t function well in these settings. Join a mission or an NGO and find where you can be most useful with the skills that you have. If you wish to give money, then give it to an organization that you know exactly what they are doing. I hope I have become a better person from this past week but I will leave that for others to judge. I will sign off by thanking PIH for creating this group, Natasha for dealing with all the nonsense of accommodations and transport, Fritz Francois for his impassioned care of patients and running this mission, Pat Poitevien for sharing her language, cultural and medical expertise and NYU for allowing and enabling us to do this mission. I also thank with all my heart: Stella, Jay, Prisca, Trish, Liz, Lucy, Pam, Joanna - the nurses. As well the nurses of Mount Sinai in NYC who were wonderful and I am grateful to them. I also thank Craig, Emily, Monica, Daina, and Dave the anesthesiologists and all others I have forgotten who made this an unforgettable and effective journey. To Ken, Gary, John, Mary Ann, John, Bill and Joaquim -the surgeons, you truly were the best and most humane group of now true colleagues and friends I ever could have hoped to work with.

By noon steady sunlight streaming through the small windows of the critical care unit had become tributaries to the stiffling humidity and heat on the ward. A few volunteers had arrived to assist the patients. They were cherubic faced US college students who wore bright yellow t-shirts announcing their affiliation with a Scientology group. They assisted with turning the patients, changing dressings, and running errands. In search of water I walked out of the unit, first past the white, then the green iron gates to arrive outdoors. I stopped and allowed my eyes to acclamate to the bright light and to survey the scene. One of the main arteries of the hospital grounds coursed directly in front of the unit. The road was congested with soldiers, transporters, doctors, patients, and families only barely avoiding crashing into one another.

A few lumbering trucks delivering supplies blared their horns in hopes that a path would somehow open up without someone getting trapped beneath their wheels.

"The Forest" stood directly across the road and I could hear voices, mostly women, joyfully singing church hymns. All around the outskirts of "The Forest" and along the road that encircled the medical campus, tents had been erected. Each tent or set of tents was labeled with the following information:
1. Service provided: Pediatrics, Post-op, Pre-op, etc.
2. Physician in charge: Dr. "Bruce", Dr. "Jim", Dr. "BB", etc.
3. Affiliation: Association of Haitian Physicians Abroad, Red Cross, Red Crescent, International Medical Corps, Swiss, Norwegian, etc.
The International Medical Corps (IMC) was responsible for coordinating the medical efforts at the hospital. They consisted of physicians with disaster relief experience. In essence they served as the de-facto leadership since so many in the hospital administration had been directly affected by "The Event". The biggest challenge that the IMC faced was how to coordinate all the responders in the most efficient manner, how to transfer critical patients when needed, and how to get necessary supplies and equipment.
In the rush to provide services reflecting the expertise of various groups, the medical campus had been splintered into silos that were now struggling to integrate not only with themselves but also with the Haitian faculty of the General Hospital. This was a problem even within particular fields such as surgery where battle lines were seared along institutional affiliations: Mt Sinai, NYU, Boston, etc. Some groups were more successful than others at bridging those divides and found a way to work together. Others, feeling wronged when it came to access to patients and procedures, packed up and left Haiti before completing the time they had promised to serve.
As I stood in front of the unit, a thin young man about seventeen years old wearing a black knapsack approached me. He was one of many such young men I had seen lurking around the hospital grounds. Some worked as transporters, others as interpreters, but the vast majority didn't seem to have a role. Reaching my location the young man briefly raised his open right hand as a form of greeting, and nodded his head while reading my name. Physicians had begun to write their names directly on their shirts or on a piece of white medical tape that they then applied to the left upper chest region. My "name tag" read: "Dr. Fritz".
Given the popularity of the name "Fritz" (or of its derivation) in Haiti, the young man quickly surmised my background and began speaking to me In Creole. After introducing himself as Jean-Marc and telling me of his losses in the quake, he proceeded to ask for my assistance in securing a job at the hospital. I listened quietly and intently but then in turn had to explain my limited role as a visiting volunteer to the hospital. Jean-Marc remained unconvinced that my status as a physician could not somehow secure employment for him and although he continued to smile politely his disappointment was unmistakable. Many other such encounters would take place in the days to come, and my ability to assist would not improve. As Jean-Marc walked away, I wondered whether a similar life with limited opportunities would have befallen me had I not gone to the US at the age of 10. This was my first time back to Haiti since I left...my first chance to reflect, on the ground, how different things could have been, and to wonder how different things will be.
As a group we were here to help repair broken limbs, overworked hearts, clogged kidneys, inflammed livers, drowning lungs, swollen bellies, and infected wounds. We labored tirelessly in the operating rooms, in "The Forest", in the critical care unit, and in the tents.
But perhaps those whose suffering could most easily be alleviated...those representing Haiti's future...those like Jean-Marc...we simply did not see at all.